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Page 14 of 19 Maqboul et al. Mini-invasive Surg 2021;5:44 https://dx.doi.org/10.20517/2574-1225.2021.54

functioning, body image, and sexual functioning. The ORC group reported higher gastrointestinal
symptoms of flatulence, irregular bowel habits, and abdominal bloating, which result in delayed return to
normal daily activities and impaired role functioning (occupational, social, and financial roles), whereas
patients who had RARC tend to experience more impairment of urinary symptoms and problems. Further
results are expected with longer follow up reflected by urodynamic studies in both groups .
[25]
[26]
Simone et al. assessed outcomes for prostate capsule and seminal vesicle sparing cystectomies to assess
alternative techniques to improve the functional outcome. The results of 2-year follow-up on 20 patients
who had organ-confined disease at TURB, negative urethral biopsy, and PSA < 4 ng/mL showed better
continence and sexual function but worse oncological outcomes with a higher local recurrence rate of 20%
and distant metastasis rate of 30%. It suggests a more traditional approach to nerve-sparing when dissecting
the prostate, including excising the seminal vesicles with the prostate, may be a better technical approach
[26]
when aiming to maximize functional outcomes .
A summary of pooled analysis and outcomes of the series review is in [Table 4].

Trials
Evidence from recent trials has contributed to the outcomes debate. The RAZOR trial demonstrated that
RARC is non-inferior to ORC for oncological outcomes, although the urinary diversion approach was
extracorporeal in this trial. The two-year progression-free survival was 72.3% in RARC vs. 71.6% in ORC
with no significant differences in lymph node yield, positive surgical margins, complication rates, or QoL
[24]
assessments . The results of the iROC trial investigating RARC with ICUD (both ileal conduit and RIN) in
comparison to ORC and ECUD are anticipated. For this study, participating surgeons must have completed
at least 30 procedures of each, which will be close to the plateau of their learning curves. The study will
report on oncological, perioperative, functional, and cost outcomes for RARC with ICUD and hopefully
make a major contribution to the literature, potentially resolving some outstanding areas of doubt in the
argument for RARC and ICUD vs. the open approach .
[27]
Specific tips and tricks for the Karolinska modified Studer U bladder (see Table 5)
As has been highlighted, longer OR times may contribute to surgical trauma, influence postoperative
complications, and mean prolonged Trendelenburg position, and negatively influence economics and cost
analyses. Having a fastidious and reproducible step-by-step approach will allow smooth progression of the
procedure and timely completion as well as faster progress up the learning curve for surgeons under
mentorship. These tips and tricks highlighted in Table 5. aim to facilitate this process.

Economics
The question of economics is relevant to the widespread adoption of RARC and RIN as a form of urinary
diversion. The intracorporeal orthotopic reconstruction may increase operative time but also has the
potential to increase morbidity and complications, both of which may increase costs. Although the evidence
is conflicting, and there may be institutional variation in cost-effectiveness, the general consensus is that
RARC is more expensive than ORC . Using Prisma Methodology to select relevant studies, a recent review
[28]
examined segmental costs to breakdown where the additional cost for RARC lies, examining the results
from a total of 11 series. Operating costs, which included surgeon fees and occupation of the OR, both
heavily dependent on OR time, accounted for 63.1%-70.5% of overall RARC costs, which will likely further
increase with the addition of RIN . Interestingly, in an earlier study, Lee et al. highlighted differences in
[29]
[28]
costs between Neobladder and Ileal conduit after RARC, finding RARC and ileal conduit had a cost
advantage over ORC of $4846, which was reversed to -$1966 if neobladder was done. Of note, for this study,
all urinary diversions were extracorporeal, although extrapolating this to RIN will likely exacerbate the